LPN scope of practice a little too broad?(LONG)

[chad75]

A little history,

I have been an LPN for approximately five years in the state of Arkansas, the first three of those in the adolescent/adult acute mental health setting. I quickly became disenfranchised with my role (pill pusher) and finally decided I would go back to school for my ASN.

I thought it would be in my best interest to gain some of my skills back before going back to school, so I applyed at a local hospital to work in their med/surg unit, I chose this hospital because it still did primary care nursing versus team. My orientation was very brief (approx. two twelve hour shifts) I was very uncomfortable given my lack of experience on medical floors but I am a quick learner and I caught on rather quickly.

I was quite frankly amazed at the amount of duties I was not only permited, but required to do. I explained to my NM that I had no experience inserting, maintaining or administering meds through an IV, CVL etc. I was promptly scheduled for what they call out here a LPN II class. The class consisted of two eight hour days of instruction on how to insert IV cathters, push meds, drop NG tube, maintain and draw from CVL and a few more things I don't remember.

Suffice it to say I didn't really feel comfortable doing all the things I was taught in 16 hours to sick REAL patients, so I would usually drag another nurse with me the first few times I performed a new procedure. I quickly realized that the buck stopped with me, I was responsible for ALL of this patients care, no RN safety net to fall back on. Yes I could go to the charge nurse if I was unsure about something etc., but if the proverbial ****** hit the fan it was my ass on the line.

I started to wonder if all this was copacetic with my scope of practice as an LPN, in Arkansas LPN's are technically not permited to "assess or evaluate" only report objective findings. Yet here I was doing admission assesments, head to toe assesments, neuro checks etc. Once a shift the RN was required to make one narrative entry in the chart, they would basically come by and write Pt. resting quietly, eyes closed 0 s/s of acute distress noted. (I worked night shift).

I called my state board and did various other reasearch and was basically told that the majority of duties I was performing were in my scope of practice as long as I was under the supervision of an RN. I guess supervision of an RN is a rather subjective term and the hospital justified it by having a "Charge Nurse".

Now don't get me wrong, I enjoyed the autonomy but then it struck me one day, here I am pushing morphine, dropping NG tubes filling out assesments, starting IV's etc. basically functioning as an RN with all the responsbility and legal liability minus hanging blood/blood products and doing care plans but have only received 16 hours training in a few traditionally RN type duties and am only being compensated as an LPN.

I began to wonder what if something really bad happened, I made a mistake or I didn't catch something in an assesment would the charge nurse have been responsible also, since I was technically working under the supervision of an RN? Why would an RN take that responsbility?

I soon after put in my two week notice, I had planned on leaving anyways due to the "new" unit manager refusing to hire nurses stating that 1:9 nurse to patient ratio was perfectly okay on a med/surg unit.

I hired on at a few agencies and eventually took a position at a Long term acute care facility (no not a nursing home, are average patient is on a vent, receiving TPN with a MRSA infected decube lol). This facility employed team nursing, and the average nurse to patient ration 2:7, 1 RN and 1 LPN to seven patients. I was only reponsible for PO meds, IVPB meds and chart checks, the RN was responsible for Nursing assesments, charting, IVP meds and dressing changes.

I am a little wiser now, I no longer wish to take full responsbility for patient care, yes I "CAN" start an IV, do an assesment, drop an NG tube, push IV narcotics etc. and many times I have been asked to by the RN I am working with but now I say NO and explain myself if the RN cares to hear my explanation. I am not compensated to do this, I have not received the amount of training you have to do this and most of all if I do it and screw it up its your ass for delegating it to me.

Am I wrong for thinking like this? Yes I will still assist a new RN with a difficult IV insertion etc. but I refuse to play RN while being compensated as an LPN! I am currently working towards receiving my ASN via excelsior, and once I pass state boards and am a Registered Nurse I will gladly take that responsbility, in the mean time I will gladly work under the SUPERVISION of my RN.

[sueb]

Personally, I am for doing anything my license allows me to do.I believe the more skills I have, the more valuable I am. If I then end up doing somebody else's work because they are taking advantage....well then I guess I'm the stupid one!

[Bambi]

No, you are not wrong. You have the ability to think through things and have the guts to stand up for what you believe is right. I commend you for standing up for yourself, and thinking about your future. If you make a mistake out of your scope of practice, it will be your license on the line, and you will have to answer for yourself. So keep protecting yourself, no one else is going to do it for you.

[chad75]

Personally, I am for doing anything my license allows me to do.I believe the more skills I have, the more valuable I am

Why is "doing more then you are compensated, reponsible or reckognized for" looked highly upon in nursing but not so in other fields.

IE. If Joe Schmoes who works in a business office does his supervisors work for him because he is afraid of retaliation if he doesn't we consider Joe Schmoe a schmuck who won't stand up for himself (Mcfly anyone?).

Buf if Mary the LPN refused to d/c a central line etc. because she really isn't qualified nor compensated for that responsbility we consider her not a "team" player.

I feel its not about what I can legally do as an LPN anymore, because quite frankly there isn't much the state board says I can't do compared to an RN when it comes to patient care. Its more about what I am properly trained and compensated to do.

[cannoli]

It's strange how things can vary so from state to state.

I am currently in a state that does not allow LPN's to do central line draws or flushes or dressing changes. They cannot access a central line. Once it is accessed by the RN, say I access the line and hang a flush bag, they can add piggybacks to that flush line.

They cannot hang blood, the Rn has to do that, I think they can help monitor the transfusion but I think it is still the RN's responsibility.

They cannot do admission assessments and I think an Rn assessment still has to be done once every 24 hours.

They can't give PPD's, or hang TPN.

There may be other things they can't do as well.

RNs now do things that only doctors used to do.

I don't blame you one bit and I agree with your last paragraph.

I am in a southeastern state.

I could be wrong but I think the BON lets the nurses do whatever the hospitals want them to be doing.

The BON's function is to protect the public, from the nurse; they certainly don't do anything for or to protect the nurses.

Good luck.

[ktwlpn, LPN]

Originally posted by sueb

Personally, I am for doing anything my license allows me to do.I believe the more skills I have, the more valuable I am. If I then end up doing somebody else's work because they are taking advantage....well then I guess I'm the stupid one!

Yeppers-sounds like a no-brainer to me....Always know your states practice act...And do you know how many actual clinical hours of training an RN receives for the same tasks? If you are technically not permitted in your state to perform admission assessmments then DON"T DO THEM....I believe you are permitted to perform neuro checks and other assessments as long as the RN covering you is doing her or his required assessments..if they are not doing so then you are not responsible for their actions.....Are you capable of monitoring your patients and reporting any changes to the RN covering you? If you have one that looks fishy you had better call the RN in to check them out....They ARE your safety net...I seldom felt like I was not getting the support I needed in med-surg...and If the rn covering me was swamped I went to another if I felt I had a problem..The attitude of "I am not doing one more thing then I am getting paid for" is exactly what makes some nurses not care to work with others....It's a great way for the LPN to take themselves right out of the job market because guess what? They don't really need us or aides either...Plenty of units employ RN's only......

[jnette, ASN, EMT-I]

Chad... I think you're doing the right thing. While by law you are ALLOWED to do the above mentioned things, I can understand your concerns.. as well as your thoughts about being compensated for them. I have a good friend who was as LPN in NC for many years... ( there, too, LPNs do EVERYTHING the RN does INCLUDING hanging blood.. only thing they DON'T do is the initial admission assessment). After so many years of this, she decided to go back to school and get her RN. She, too, went through Excelsior (then Regents) eight years ago. Guess she thought "hey, if I'm already DOING all this, I might as well be COMPENSATED for it !"

She's been an RN for 8 years now. And while the skills are no different, she does agree that the LEARNING behind those skills was very helpful and gave her a far deeper understanding of WHY she was doing WHAT she was doing ... as well as the possible effects on the patient, etc., etc.... she has never regretted the far more "in depth" learning surrounding those skills she was already performing.

So yes.. I'm all for what you're doing. You've got your head on straight. Go for it... learn all you can and do all you are COMFORTABLE with until you graduate, but no more. I beleieve you'll do quite well... good for you ! :)

[chad75]

you are technically not permitted in your state to perform admission assessmments then DON"T DO THEM

To add some more detail about that, the hospital eventually ended up changing the form to a 2 part, the LPN did one part and the RN did other part, what eneded up happening though is most of the LPN's did all of it with an RN co-sign.

Are you capable of monitoring your patients and reporting any changes to the RN covering you?

The fact of the matter is, I had no designated RN covering me to report to. Yes we had a charge nurse who took their own patients, it was a primary care setting.

If you have one that looks fishy you had better call the RN in to check them out....They ARE your safety net

In the setting I was working in, if I had a patient that was starting to look "fish" I would usually grab the charge nurse if I could find her, or call the physcian with what was going on. I don't think you understand the setup we had on this med/surg unit, we usually had 2 RN's and 3-4 LPN's on duty, we split the patients equally so It was like the RN's could care for 40 patients, while also taking care of their 7 patients.

he attitude of "I am not doing one more thing then I am getting paid for" is exactly what makes some nurses not care to work with others....It's a great way for the LPN to take themselves right out of the job market because guess what? They don't really need us or aides either...Plently of units employ RN's only......

I knew someone would take this as me whining about not getting payed for what I do, in all honestly that just about 40% of my rant lol, I am also not trained to the level of the RN to perform these duties and I feel some hospitals are taking advantage of the wide scope of practice of LPN's when its not in the patients/RN's/LPN's best interest. If you think 16 hours of theory is appropriate training for the procedures RN's are usually responsible for then I guess I am mistaken.

As far as the "they don't need us comment", I must ask how long you have been in health care and how many times have you seen hospitals phase out LPN's/support staff/aids...How long did it last? Not long I gaurauntee you, they actually do need us. Critical areas are the only units I know of that don't normally employ LPN's, but guess what there is a 1:2 staffing ratio normally, there aren't enough RN's in the entire world to just staff the United States Med/Surg/Ortho/SNF units :)

[Tweety, BSN, RN]

Sounds like they are using you the way our hospital uses LPNs. As primary care providers. The charge nurse however, is the designated RN to cover the LPN here. The reality is in our hospital the LPN cannot be in charge, but basically there is little difference between the responsibilities. The difference being 5-8 dollars an hour.

I don't hear many complaints from the LPNs about their scope of practice. In fact get highly offended if an RN tries to interfere too much. Fortunately the two LPNs I work with have a combined experience level of 50 years and are teaching me things.

[SKM-NURSIEPOOH, BSN, RN]

i wouldn't do *anything* that would make me uncomfortable in anyway! i give someone more credit for realizing & acting on the fact that they're faced with a situation that's out of their scope of practice & know not to proceed!

i can't understand why any rn would delegate tasks that they *should* know are out of the scope of lpns. is it cuz they don't know the l's scope of practice within their state? employers would try to make the rs ultimately responsible for the ls...despite the fact that ls do have their own licenses to protect. employers go with the broad statement of ls coming under the supervision of the rs....it doesn't really matter which rs they come under...just that there's one around! sooo if you're working on a unit that has say three ls & four rs....which r would the ls license come under should anything go wrong with a patient? would it be the charge r or would it be the r who delegates things to the ls...even if that r isn't the charge. and more importantly...will the r who is in charge be held responsible for the r who delegated a non l scope task cuz she's in charge of the entire floor? where does all of that end...i mean...the charge is being supervised by the shift r....& so on! sbon do really need to become more clear with the respects of what ls can & can't do & shouldn't make vague/broad/blanketed statements that could be left to all sorts of interpretation!

cheers!

moe

[chad75]

3rdshiftguy,

Yes some LPN's take as an insult that hospital policy/state board etc. says they can't do some things, just like some RN's take offense that they can't write an order for tylenol legally.

I would even go as far as saying that would have described me right out of nursing school, but I am older and slightly wiser now. Nursing is a career and just like any other career people like myself don't work for free. I am not Florence Nightingale, nor do I claim to be. I am however a damn good at what I do, however I didn't receive recognition, compensation or even appropriate education for the tasks I was required to do at my previous employer and quite frankly I am seeing a trend at least in this state of hospitals making previous RN only procedures/duties the responsbilities of the LPN's.

Are LPN's receiving across the board signifigant financial compensation for these duties ? No. Are LPN's given suffcient education on these procedures, not just doing them but the reason we are doing them? In my opinion no. Is administration suddenly recognizing LPN's for their greater role in the health care team beyond pill pusher? In my experience no.

[ktwlpn, LPN]

Originally posted by chad75

quote

The fact of the matter is, I had no designated RN covering me to report to. Yes we had a charge nurse who took their own patients, it was a primary care setting.

>>>>>>>>. In my state even in the primary nursing model I had RN's covering my patients-to carry out the things that were not within my scope of practice,.They took this very seriously and valued their own licenses,too....They always did the assessments as the law requires ....

quote

As far as the "they don't need us comment", I must ask how long you have been in health care and how many times have you seen hospitals phase out LPN's/support staff/aids...How long did it last? Not long I gaurauntee you, they actually do need us. >>>>>>>>>.. Not around here-I have been an LPN since 1988 and have seen this happen at 2 out of 3 local hospitals...They do occassionally re-hire a few LPN's and aides but they are the first to go when the cut backs start....I believe that the acute care system does need LPN's but that we must function to the fullest extent of our scope and training or we will become extinct....If the RN"s are co-signing your assessments without assessing the patient themselves then they are not following the requirements the way I understand them....They actually have to perform an assessment in Pa.I do think that 16 hours of training more then prepares you to sink an NG ,start an IV or maintain and draw from a central line...I went to a really good nursing program-LPN's from that program are highly sought after in this part of the state-we are well prepared to function within our scope of practice....